35 Questions
What is the most common site of atherosclerotic lesions?
Branch points and along the outer surfaces of arterial curves
What is the primary goal of perioperative beta-blockade?
To reduce the risk of cardiovascular events
What is the estimated risk of MI or cardiac-related death for high-risk surgical patients?
Greater than 5%
What is the characteristic of secondary Raynaud's disease?
B and C
What is the goal of anesthesia management in a patient with Raynaud's disease?
Reduce vasospasm
What is the most common cause of carotid artery disease?
Embolic problem
What is the definition of a transient ischemic attack (TIA)?
Sudden onset of vascular-related focal neurologic deficit that resolves within 24 hours
What is the leading cause of disability in the United States?
Acute ischemic stroke
What is the primary cause of declamping hypotension?
Central hypovolemia due to redistribution of blood volume
What is the percentage of reduction in spinal cord blood flow during proximal descending aorta clamping?
90%
What is the most common symptoms of anterior spinal artery syndrome?
Flaccid paralysis of lower extremities
What is the goal MAP during anesthesia for thoracic aortic aneurysm?
100 mmHg
What is the definition of an aneurysm?
A 50% increase in arterial diameter
What is the primary risk factor for abdominal aortic aneurysm rupture?
Diameter > 5 cm
What is the classic triad of symptoms for abdominal aortic aneurysm rupture?
Hypotension, back pain, and pulsatile abdominal mass
What is the ankle-brachial index for ischemic ulceration/impending gangrene?
< 0.25
What is the primary advantage of regional anesthesia for peripheral arterial disease?
All of the above
What is the primary operative risk factor for surgery in peripheral arterial disease?
Associated atherosclerotic disease
What is the third leading cause of death in the U.S.?
Stroke
What is the recommended overall complication rate by a surgeon in an institution for operating on asymptomatic CEA patients?
< 3%
What is the primary consideration in determining the need for shunting during carotid endarterectomy?
Determination of cerebral ischemia
What is the goal of anesthesia management during carotid endarterectomy?
Hemodynamic stability and rapid emergence
What is the recommended blood pressure control during carotid endarterectomy?
High-normal blood pressure
What is the complication rate of stroke, death, or cardiac event during carotid endarterectomy?
4.0%
What is the benefit of using regional anesthesia compared to general anesthesia during carotid endarterectomy?
17% reduction in stroke, 24% reduction in death, 33% reduction in cardiac event
What is the recommended postoperative blood pressure management?
Promptly addressing hypertension to reduce neurologic deficit risk
What is the major complication of carotid angioplasty and stenting?
Microembolization
What is the recommended timing for addressing postoperative hypertension?
2-3 hours postop
Which of the following beta-blockers has been shown to have the most benefit in perioperative beta-blockade?
Bisoprolol
What is the recommended transfusion threshold for patients undergoing perioperative beta-blockade and anemia?
60% of baseline hemoglobin
Which of the following is a benefit of perioperative statin therapy in vascular surgery patients?
All of the above
What is the classification of aortic dissection that involves the ascending aorta and aortic arch?
DeBakey Type II
What is the primary focus of preoperative preparation for patients with aortic dissection?
All of the above
Which of the following alpha2 agonists has been shown to reduce intraoperative myocardial ischemia and catecholamine levels?
Clonidine
What is the recommended duration of continuation of beta-blockade in high-risk patients undergoing high-risk surgery?
7-30 days
Study Notes
Aortic Clamping and Unclamping
- Aortic clamping results in increased afterload and decreased cardiac output, leading to left ventricular dysfunction.
- Proximal descending aorta clamping leads to a 90% reduction in spinal cord blood flow, renal blood flow, GFR, and urinary output.
- Gradual release of clamp is preferred to minimize hemodynamic changes and washout of vasoactive metabolites.
- Declamping hypotension is caused by central hypovolemia, hypoxia-mediated vasodilation, and release of vasoactive and cardiodepressant metabolites.
Anterior Spinal Artery Syndrome
- Two posterior spinal arteries and one anterior spinal artery supply the spinal cord.
- The anterior spinal artery is supplemented by radicular arteries, including the artery of Adamkiewicz.
- Watershed areas exist where blood supply is at risk, leading to spinal cord ischemia.
- Perfusion is compromised by resection or exclusion of the artery of Adamkiewicz, reduced aortic blood flow, and increased CSF pressure.
Miller's Thoracic Aortic Aneurysm
- Aneurysm is defined as a 50% increase in arterial wall diameter.
- Signs and symptoms include compression of adjacent structures, such as the left recurrent laryngeal nerve, trachea, esophagus, lungs, and superior vena cava.
- Classification of aneurysm is based on location and extent.
Abdominal Aortic Aneurysm (AAA)
- Etiology is related to degradation of extracellular matrix proteins.
- Signs and symptoms include exsanguination, pulsatile abdominal mass, and rupture.
- Surgery is indicated at a diameter > 5 cm, with an annual expansion of > 0.6-0.8 cm.
Peripheral Arterial Disease (PAD)
- Risk factors include diabetes, hypertension, smoking, dyslipidemia, and hyperhomocysteinemia.
- Signs and symptoms include intermittent claudication, rest pain, and ischemic ulceration.
- Medical management includes exercise, smoking cessation, and lipid-lowering drugs.
- Surgical management includes thromboembolectomy, surgical reconstruction, and endovascular procedures.
Perioperative Beta-Blockade
- Benefits include reduced cardiac morbidity and mortality, but may increase risk of stroke and death in certain patients.
- Initiation of beta-blockade is recommended for high-risk patients undergoing high-risk surgery.
- Dosage and titration are important, with a target heart rate of 60-80 bpm.
Statin Therapy
- Perioperative statin therapy is associated with reduced mortality following vascular surgery.
- Benefits are attributed to pleiotropic effects, including improvement of endothelial function, reduction of vascular inflammation, and stabilization of atherosclerotic plaques.
Alpha2 Agonists
- Clonidine reduces intraoperative myocardial ischemia and catecholamine levels.
- Meta-analysis shows a reduction in cardiac morbidity and death following vascular surgery.
Timing of Vascular Surgery
- Following MI, the incidence of perioperative reinfarction decreases with time, stabilizing at 6 months.
- Following CABG, surgery is recommended after 4-6 weeks.
- Following angioplasty, surgery is recommended after 2 weeks.
- Following stent placement, surgery is recommended after 6-12 months.
Barash CARP Trial
- Coronary artery revascularization prior to elective vascular surgery is not indicated unless independently indicated for acute coronary syndrome.
- Both groups had similar characteristics, including > 80% on beta-blockers, > 70% on ASA, and > 50% on statins.
This quiz covers the key concepts of atherosclerosis, including its development, common sites, and concurrent diseases. Test your understanding of the overlap of vascular disease, distribution of atherosclerotic lesions, and more.
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